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SAKJOAQUIN <br />—COUNTY— <br />Well #2 Information <br />❑ Domestic ❑ Irrigation <br />Use of Well: <br />❑ Other. <br />Total Depth (ft): <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />Annual Extraction Volume (acre-feet. <br />Other Pumping Tests Perfonneaa _ <br />Well #3 Information <br />❑ Domestic ❑ Irrigation <br />Use of Well: <br />❑ Other. <br />Total Depth (ft): <br />Casing Diameter (in): <br />Pumping Rate (gpm): <br />Annual Extraction Volume (acre-feet: <br />Specific Capacity (gallminlft): <br />Other Pumping Tests Performed. <br />Environmental Health Department <br />❑ Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑ Stock <br />To: jFrom:To: ❑ Open Bottom or Screen Interval (ft): <br />To: <br />❑ Estimated ❑ Measured <br />Test <br />❑ Small Public Water Supply [3Municipal Public Water Supply ❑ Industrial ❑ Stock <br />70: <br />❑ Open Bottom or Screen Interval (ft): T0: <br />To.. <br />WATER TABLE IDNFpORMAth knF STIION"ource of Reference: <br />Current Water Table: <br />Highest Water Table: <br />Lowest Water Table: <br />Recharge Area: <br />SITING INFORMATION' onsite: <br />Distance To Nearest (ft): <br />Wastewater Treatment System: <br />Onsite Well: <br />Animal of Fowl tnciusw- <br />❑ Estimated 0 <br />Test <br />Offsite: Distance To Nearest (ft): <br />Transmission Lines: <br />PondlLake: <br />StreamlRiver. <br />Onsite: <br />From: <br />From: <br />From: <br />of <br />MOINFaRM TION <br />A <br />ma of the well location must be attached to this form and shall include the followinginformation: <br />Le allot and arcel dimensions. each well. 1� 11a, <br />All well locations on I al lot and arcel wtial sources of a rllutionaornsit a d onrad scent ro emi�ion liners, sewer lines. <br />Distance from ro sed well to an <br />ten trans <br />o Existin or ro sed onsite sewastee ms within 300 feefWelis, animal or fowl enc osurutili corridors, and roads within two miles. <br />o Distance from nds, lakes, and canals, relines, <br />o For wells below Corcoran cls , ma must show location <br />ois rtand truthful to the extent reasonably known. <br />I hereby certi t in f ation I have providedDate: <br />Signed: <br />Well Driller 11WeIVProperty Owner ❑ Other: <br />Information Prov By: <br />2of2 <br />EHD 4300 `12-21'2017 <br />